At the Intersection of Health, Health Care and Policy Cite this article as: Ben Butler and Judy Murphy The Impact Of Policies Promoting Health Information Technology On Health Care Delivery In Jails And Local Communities Health Affairs, 33, no.3 (2014):487-492 doi: 10.1377/hlthaff.2013.1125
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Jails
&
Health
By Ben Butler and Judy Murphy 10.1377/hlthaff.2013.1125 HEALTH AFFAIRS 33, NO. 3 (2014): 487–492 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
The Impact Of Policies Promoting Health Information Technology On Health Care Delivery In Jails And Local Communities
Ben Butler (bbutler@cochs .org) is chief information officer at Community Oriented Correctional Health Services, in Oakland, California.
The 1976 Supreme Court decision in Estelle v. Gamble declared that jails must provide medical treatment to detainees consistent with community standards of care. Yet despite their important role providing health care to about ten million people a year, jails remain largely siloed from the surrounding health care community, compromising inmates’ health and adding to health care spending. Health information technology promises solutions. The current policy landscape, shaped by the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Affordable Care Act, is favorable to jails’ implementation of health information technology (IT). In this article we examine how decisions largely external to jails—coming from the Supreme Court, Congress, and local policy makers—have contributed to the growth of health IT within jails and health information exchange between jails and local communities. We also discuss privacy concerns under the Health Insurance Portability and Affordability Act and other legislation. This article highlights a rare confluence of events that could improve the health of an overlooked population. ABSTRACT
A
s providers of health care, jails face many of the same challenges that community health care providers face: how to provide better care, including better continuity of care, at lower cost. Yet jails face unique challenges as well. They provide health care to a highly mobile, largely uninsured population with higher-thanaverage rates of mental illness, substance abuse, and chronic diseases such as diabetes and HIV/ AIDS. And they often do so without benefit of linkages to local health providers. Without accurate medical information about inmates upon admission, jails sometimes struggle to provide adequate, timely care. And without continuing care in the community, former inmates’ health suffers, and they add to the community health burden, ultimately increasing health spending. Health information technology (IT) promises solutions. The movement to implement new in-
Judy Murphy is deputy national coordinator for programs and policy at the Office of the National Coordinator for Health Information Technology, Department of Health and Human Services, in Washington, D.C.
formation technologies, including electronic health record (EHR) systems and health information exchange, has accelerated across the mainstream health care delivery system, largely in response to a range of federal policy initiatives, technological developments, and market forces. Adoption of health IT by jails has in many ways mirrored adoption efforts by providers outside the jail walls. Some jails continue to use paper records, but others are migrating to EHR technology. A few have relatively sophisticated information systems that interface with jail management systems, EHRs, pharmaceutical systems, and electronic medication administration records. Some pioneering jurisdictions, such as Hampden County in Massachusetts, have developed their own EHR systems. Others have purchased and implemented systems developed for non–correctional settings, such as products used in hospitals or clinics. EHR systems developed March 2014
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Health specifically for correctional settings are also available. In addition, several proprietary companies that contract to provide health care in correctional facilities have developed their own EHR systems for implementation among their prison and jail clients. Fortunately for the nation’s jails, the policy environment is favorable for the adoption and expansion of EHRs and other health IT in the correctional setting. In this article we examine how decisions external to jails—coming from the Supreme Court, Congress, and local policy makers—have contributed to the growth of health IT in jails, leading to an opportune moment for many jurisdictions to intensify their efforts to adopt health IT, implement it more effectively, and use it to create connectivity between their jail and the surrounding community. We begin with the 1976 US Supreme Court decision in Estelle v. Gamble and continue through the 2009 passage of the Health Information Technology for Economic and Clinical Health (HITECH) component of the American Recovery and Reinvestment Act (ARRA) and 2010’s Affordable Care Act (ACA). Although many of the forces we identify are national in scope, local communities will play a major role in implementing health IT in jails. By way of example, we look at four jurisdictions where local forces furthered health IT in jails. The range in sophistication these systems represent provide a snapshot of where our nation’s jails are now with regard to health IT. In this article we also consider challenges that the Health Insurance Portability and Accountability Act (HIPAA) presents with regard to health IT in jails and how some jurisdictions have overcome them.
Background On The Jail Population Every year about ten million people are incarcerated in the nation’s 3,300 local and county jails. As a population, they have significantly higherthan-average rates of mental illness; substance addiction; and chronic and infectious diseases, including hypertension, diabetes, tuberculosis, HIV/AIDS, and hepatitis B and C.1 Unlike prison inmates, who are incarcerated for sentences of at least a year, jail detainees are generally released quite quickly back into their home communities, with 60 percent out within a week.2 After release, without insurance or a regular care provider, they generally go without continued treatment for whatever health problems they may have, which then worsen and become part of the community health burden. Thus, the investment made in inmates’ health while they are in jail is lost almost as soon as they return to the community. Untreated health 488
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problems, particularly mental illness and substance abuse disorders, often contribute to repeat offenses and recidivism, which, of course, incur additional costs to society. Meanwhile, as in the mainstream health care delivery system, health care costs present a serious challenge to many correctional institutions, which typically spend 9–30 percent of their budgets on inmate health care services. In Washington, D.C., for example, inmate medical services at the jail cost about $33 million in 2012, a quarter of the city’s annual corrections budget.3 Camden County, New Jersey, spent $11 million for inmate health care—22.25 percent of its health care budget and approximately 3.2 percent of the county’s entire $343 million budget for 2013 (Holly Cass, County Operations at County of Camden, New Jersey, personal communication, September 2013). The Multnomah County (Oregon) Health Department spent $2.8 million on health care in Portland’s jails— approximately 9 percent of the department’s budget (Nancy Griffith, Multnomah County Health Department, personal communication, September 2013).
Estelle V. Gamble The US Supreme Court decision in Estelle v. Gamble (1976) established that jails must meet the medical needs of the people in their custody. Failure to do so violates the Eighth Amendment, prohibiting cruel and unusual punishment. The Court also established a “constantly changing standard of required care because the right [of inmates to care] is based on evolving standards of health care in the general community.”4 As the expected standard of care in the community rises to meet new demands, so does the required standard of care in the local correctional setting. For example, forty years ago HIV/AIDS had not yet been diagnosed; today 13–19 percent of people with AIDS have had involvement with the correctional justice systems.5 Likewise, forty years ago most people with serious mental illnesses were in mental hospitals; today, many local and county jails are de facto providers of mental health care in their communities. Not only did Estelle place a broad mandate on correctional facilities to meet inmates’ health care needs, but it also said that cost concerns cannot outweigh that obligation. Facilities that practice “deliberate indifference” and ignore an inmate’s serious medical need can be sued. Since the Estelle decision, correctional officials’ failure to meet the health care obligations it established has resulted in numerous costly lawsuits and injunction decrees. Estelle does not dictate to jails how they must provide inmate care. They
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may employ their own medical staff, use public health departments, or contract with individuals or companies. Today a large city jail may serve as many people as a medium-size hospital, with its own on-site clinics, laboratories, and pharmacies. For example, the New York City jail system, the second-largest in the country after Los Angeles County, conducts nearly 750,000 medical and mental health visits a year, resulting in more than 600,000 prescriptions.6 Proprietary providers such as Corizon Health and Correctional Healthcare Companies contract with hundreds of prisons, jails, and other correctional facilities across the country to provide inmate care.
Four Jurisdictions, Four Health IT Implementations The examples of four disparate jurisdictions— Orange County (Orlando), Florida); Multnomah County (Portland), Oregon; New York City; and Hampden County (Springfield), Massachusetts)—provide a snapshot of the range of health IT options jails across the country have chosen and the forces driving those choices. Florida In Orange County an oversight commission active during the 1990s issued a set of 260 recommendations for improving health care and security at the county jail in Orlando, including updating the jail’s health IT infrastructure. In response, the jail purchased a new offender management system (OMS)7 and integrated it with a new EHR. This system went live in 2005. The integration has helped the jail manage inmates’ medical risk in several ways. Demographic data entered at booking automatically populate the EHR. If the inmate is a repeat admission, his or her medical record from previous incarcerations appears. The integration also supports automatic transfer of medication order records from the pharmacy system to the OMS, providing a record of distribution. Another interface between the OMS-based inmate sick-call system and the jail’s EHR system has significantly improved triage, tracking, and documentation. Under the former paper-based system, sick-call requests could be misplaced or lost. Under the new system, requests submitted by inmates are electronically transferred to the EHR, and a nurse can then triage the requests. Oregon The Health Department in Multnomah County oversees health care at the jail. In 2006 the county auditor recommended an EHR at the jail. The Health Department had implemented an EHR in its nonjail clinics and wanted to bring it to the jails as well. This was problematic because it was a difficult EHR to implement in the jail environment: It did not integrate with the jail management system (JMS); it did not
track inmate location (location tracking is especially important in a jail setting); and its computerized physician order entry system was not compatible with the jail’s correctional pharmacy system. Despite these drawbacks, the Health Department’s overriding concern for the health care of the entire county population prompted it to adopt (after an attempt to implement a different EHR) a unified EHR system across community clinics and in the jail. The EHR in the jail went live in 2012. Fourfifths of health care providers in the Portland area now use the same EHR that is used in the jail (Jennifer McClure, Multnomah County Health Department, personal communication, May 9, 2013). This specific EHR allows for the sharing of data between different installations at hospitals, clinics, and the county’s jails, in effect allowing health information exchange. New York In New York City the Department of Health and Mental Hygiene, which oversees correctional health in the city’s eight jails, also administers the Primary Care Information Project, which supports EHR adoption among primary care providers that work with underserved populations. Because the department recognized that the jail health care system is a critical part of the community safety net system, it has been working to bring the jails into the PCIP as well. Within the jail setting, the new EHR has been integrated with the inmate information system (IIS), in much the same way that Orange County integrated its information systems, including a pharmaceutical interface. In addition, the New York City department has built interfaces between jail system’s EHR and the Brooklyn Health Information Exchange (recently merged into the Healthix, a regional health information organization, which in turn connects with the Statewide Health Information Exchange of New York). This is the first step in achieving health information exchange between the jail system and community providers. Massachusetts In Hampden County, the Sheriff’s Department, under the leadership of Sheriff Michael Ashe, developed its own EHR, which it calls HealthTRAX; it went live in September 2003. The system allows providers to enter information about inmates’ medical history, problems, diagnoses, medications, counseling, dental care, and vision care. Medication orders entered into HealthTRAX are sent electronically to the pharmacy system, which verifies orders and relays warnings back to HealthTRAX in the event of duplicate orders or potential drug interactions. Having an internally developed system means that when problems arise, they usually can be resolved in-house, without the necessity of an outside vendor or consultant. March 2014
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Health Laws Accelerate Correctional Health IT Adoption Meaningful Use The HITECH Act authorized the spending of up to $44 billion to promote the adoption of health IT. Under HITECH, the State Health Information Exchange Cooperative Agreement Program was created to fund states’ efforts to build capacity for health information exchange across the health care system both within and across states. The HITECH Act also created an EHR incentive program, in which eligible Medicare and Medicaid providers that adopt certified EHRs can attest that they are “meaningful users” in order to receive incentive payments. One of the major goals of meaningful use is to establish health information exchange—hence the emphasis in HITECH on funding the development of health information exchanges. At first, providers in correctional institutions were not considered eligible for the meaningfuluse program because they were not Medicaid providers. The criterion for being eligible as a Medicaid provider was that 30 percent of a provider’s patient volume be for paid Medicaid encounters. However, states either terminate or suspend Medicaid upon incarceration; as a result, correctional providers are not able to bill Medicaid. Even though the ACA’s expansion of Medicaid to low-income people meant that many of those cycling through jails would have a higher likelihood of being enrolled in Medicaid, this still did not allow providers in corrections to participate in meaningful use, because the billing requirement was still in effect. Correctional Providers As Medicaid Providers The ability for correctional providers to become Medicaid providers and thus participate in the meaningful-use program came about in 2012, when the Centers for Medicare and Medicaid Services (CMS) expanded criteria for certifying a Medicaid provider. This expansion allowed for Medicaid enrollment (along with paid encounters) to be counted toward the 30 percent patient volume needed for a provider to qualify as a Medicaid provider. So for correctional providers in states that have expanded Medicaid, meaningful-use incentives suddenly became an option.8 The incentive program is financially appealing to jails. Each Medicaid provider can receive up to $63,750 for completing all three stages of attestation for meaningful use (Medicaid providers who can attest for meaningful use include all physicians at the jail plus nurse practitioners and midwives). The Medicaid meaningful-use program is aimed at individual providers, but providers are permitted to assign the payment to their employer—in this instance, a correction-
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al institution. For adopting, implementing, and updating to a certified EHR, in the first year of Stage 1 of meaningful use, a Medicaid provider can receive $21,250. Challenges Attesting for all of the stages of meaningful use and thereby receiving the total incentive payment is challenging for many providers in a jail environment. For example, allowing patients access to their medical records via the Internet is a requirement for Stage 2. Meeting this requirement is potentially difficult for providers in jails, as safety and security considerations—always primary within corrections—often argue against allowing detainees such access.9 Also, the time frames are tight, since 2016 is the last year a provider can begin participating in the Medicaid meaningful-use program. Nevertheless, these developments have opened up the possibility that correctional health care providers, like their non–correctional health care provider counterparts, could be exchanging health data in order to improve care and lower costs. Among the four jails discussed in this article, only the Department of Health and Mental Hygiene in New York City has begun the attestation process. This has meant that the department has had to verify that 30 percent of its patient volume is with Medicaid-enrolled individuals, the providers are certified Medicaid providers, and the providers are assigning payment to the department. The various requirements of Medicaid meaningful use may at first glance seem trivial; however, they are nevertheless prohibitive if not met. Orange County cannot participate in the meaningful-use program because Florida has not yet expanded Medicaid, and so it is highly unlikely that the threshold of 30 percent patient volume enrolled in Medicaid can be met. Although Massachusetts has expanded Medicaid, HealthTRAX, which was developed in house, is not yet a certified EHR. The Health Department of Multnomah County has a certified EHR and is in a state that has expanded Medicaid, but it is not currently collecting enrollment status because at this time the department is not prepared to make a new business case to justify the additional investment of staff resources (McClure, personal communication, December 2013).
Privacy Laws, Health Information Exchange, And Corrections The HIPAA Privacy Carve-Out One of the main goals of the HITECH Act was to promote health information exchange, and meaningful use is one of the means to achieving that goal. Thus, it is natural to inquire how HIPAA applies to
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The environment for health IT has never been more promising than it is now, and this is encouraging news for jails.
health data exchange when correctional institutions are involved. HIPAA explicitly allows these institutions to access inmates’ health information for the purpose of maintaining safety and security.10 However, community providers do not always understand or recognize this carveout for correctional institutions, which makes it difficult for jails to retrieve such information from the community providers. In New York State the HIPAA carve-out is recognized by the Statewide Health Information Network of New York (SHIN-NY). EHR data from health care providers that participate in health information exchange organizations are loaded without requiring patient consent. However, for a provider to access data from another provider, consent must be given, except in emergencies, at the time the data are being accessed. The New York City Department of Health and Mental Hygiene considers arrest an emergency situation, so the jails’ EHR is being modified to implement this policy. In the nonjail environment, the default is to obtain consent to access data, but in the jail system’s EHR, the default will be set to emergency access. Once a person is no longer incarcerated, the jail cannot view that person’s data without obtaining consent. Becoming A Covered Entity Organizations that establish health information exchanges often require participating providers to be covered entities under HIPAA (a covered entity is a health care provider transmitting health information electronically, a health care clearinghouse, or a health plan). This is a step that some jails do not want to take because they view the consent and privacy requirements for covered entities to be burdensome. Yet the benefits for the jail to participate in health information exchange— quickly identifying known health conditions, lowering costs, and perhaps reducing recidivism by providing continuous treatment—may outweigh the burden. There are examples of jails designated as cov-
ered entities and participating in health information exchange. New York City’s correctional system, whose health care provider is a covered entity, interfaces with health information exchange (as discussed above). Kentucky’s health information exchange, known as the KHIE, requires all providers who join it to be covered entities. The director of the Lexington jail, who is in the process of joining the state’s health information exchange, was willing to designate the jail as a covered entity in order to participate. He views the exchange of health data as means to enhance the care provided at his institution (Rodney Ballard, director, Fayette County Jail, personal communication, May 17, 2013). Substance Abuse Disorders There is no carve-out for correctional institutions to access data on inmates’ substance abuse disorders.11 A federal confidentiality regulation known as 42 CFR Part 2 stipulates the privacy of information concerning substance abuse disorder treatment for organizations receiving federal funds. Because this regulation was designed to encourage people to seek treatment, it is much stricter than HIPAA with regard to privacy. In addition, the conditions of consent—to whom, for how long, and for what purpose—are very specific. As a result, many community providers involved in health information exchange avoid exchange of data related to substance abuse treatment. In response, the Office of the National Coordinator for Health Information Technology has launched an initiative to explore the sharing of sensitive data using a data segmentation approach that allows individuals to specify which data a provider may access. The outcome of this initiative could be very valuable in a post-ACA world in which mental health and substance abuse disorder treatments are covered at parity with medical benefits. As a result of parity, there is a greater opportunity for jail-involved individuals to seek help for their substance abuse disorders. It may seem counterintuitive to remove data in order to promote better health care, but data segmentation initiatives that maintain restrictions on substance abuse treatment might be beneficial for health outcomes and reducing recidivism, if fear of disclosure is preventing someone from seeking treatment. When Washington State provided substance abuse treatment to addicted, very low-income childless adults, rates of re-arrest were 17–33 percent lower, compared with those among other addicted adults who did not receive treatment.12
Conclusion Increasingly, both the health care and the criminal justice sectors are recognizing the benefits of March 2014
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Health connecting correctional health care and community health care. The justice-involved population is not a population separate from the general community. It is a subpopulation of a highly vulnerable, high-cost, and underserved population whose health problems contribute substantially to the overall community health burden. As policy makers have struggled to find ways to control soaring health care costs, it has become clear that those efforts cannot succeed without taking into account the substantial health care costs incurred by the jail population. By extending Medicaid eligibility to very lowincome childless adults, the ACA creates an opportunity to manage some of those costs, especially with regard to treatment for mental illness and substance abuse. For states that have chosen to expand Medicaid, the people cycling through jails will have better opportunities to seek treatment for their underlying health conditions in the community because they now are eligible for insurance. For states expanding Medicaid that suspend it instead of terminating it when a Med-
icaid enrollee is incarcerated, jails and their health care providers can take advantage of HITECH meaningful-use incentives to adopt EHRs and participate in health information exchanges. The environment for health IT has never been more promising than it is now, and this is encouraging news for jails. As health care providers to some ten million people a year, jails—like other health care providers—are challenged to find ways to improve care while maintaining or lowering costs. By enabling the flow of information essential for delivering more coordinated, efficient, and sustained health care to the vulnerable and costly justice-involved population, health IT can serve as a bridge connecting jails and their communities. Jails can look to HITECH and the ACA not only as a way to better fulfill their obligations to provide health care to detainees but also as a rare confluence of events that can permit them to integrate within the greater health care community. ▪
NOTES 1 Conklin TJ, Lincoln T, Wilson R. A public health manual for correctional health care. Ludlow (MA): Hampden County Sheriff’s Department; 2002 Oct. 2 Minton TD. Jail inmates at midyear 2012—statistical tables. Washington (DC): Department of Justice, Bureau of Justice Statistics; 2013 May. 3 Schaenman P, Davies E, Jordan R, Chakraborty R. Opportunities for cost savings in corrections without sacrificing service quality: inmate health care. Washington (DC): Urban Institute; 2013 Feb 26. 4 Wright LN. Health care in prison thirty years after Estelle v. Gamble. J Correct Health Care. 2008;14(1): 31–5. 5 Veysey B (Rutgers—The State University of New Jersey, Newark, NJ). The intersection of public health and public safety in U.S. jails: implications and opportunities of federal
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health care reform [Internet]. Oakland (CA): Community Oriented Correctional Health Services; 2011 Jan [cited 2013 Oct 1]. Available from: http://www.cochs.org/files/ Rutgers%20Final.pdf 6 Stazesky R, Hughes J, Venters H (Department of Health and Mental Hygiene, New York, NY). Implementation of an electronic health record in the New York City jail system [Internet]. Oakland (CA): Community Oriented Correctional Health Services; 2013 Apr [cited 2013 Oct 1]. Available from: http:// www.cochs.org/files/hieconf/ implementation-ecw-new-york.pdf 7 The functions of an offender management system (OMS)—sometimes called an inmate information system (IIS) or a jail management system (JMS)—include tracking housing or location of inmates; inmate calendars, which can include court dates
8 9
10 11 12
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and medical appointments; dietary restrictions; bunking assignments due to physical disabilities; and other crucial information necessary for the running of a correctional institution. 45 CFR parts 412, 413, and 495. Access to computers, especially access to the Internet, is perceived as a threat because it presents the possibility of permitting communication that can be related to gang issues, contraband, and other criminal activity. 45 CFR sec. 164.512. 42 CFR part 2 sec. 2.1. Mancuso D, Felver BEM. Providing chemical dependency treatment to low-income adults results in significant public safety benefits. Olympia (WA): Washington State Department of Social and Health Services, Research and Data Analysis Division; 2009 Feb. (Report No. 11.140).
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/3/487.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on June 22, 2015 at UNIV OF HAWAII at Manoa Jabsom
Jails
&
Health
By Ben Butler and Judy Murphy 10.1377/hlthaff.2013.1125 HEALTH AFFAIRS 33, NO. 3 (2014): 487–492 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
The Impact Of Policies Promoting Health Information Technology On Health Care Delivery In Jails And Local Communities
Ben Butler (bbutler@cochs .org) is chief information officer at Community Oriented Correctional Health Services, in Oakland, California.
The 1976 Supreme Court decision in Estelle v. Gamble declared that jails must provide medical treatment to detainees consistent with community standards of care. Yet despite their important role providing health care to about ten million people a year, jails remain largely siloed from the surrounding health care community, compromising inmates’ health and adding to health care spending. Health information technology promises solutions. The current policy landscape, shaped by the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Affordable Care Act, is favorable to jails’ implementation of health information technology (IT). In this article we examine how decisions largely external to jails—coming from the Supreme Court, Congress, and local policy makers—have contributed to the growth of health IT within jails and health information exchange between jails and local communities. We also discuss privacy concerns under the Health Insurance Portability and Affordability Act and other legislation. This article highlights a rare confluence of events that could improve the health of an overlooked population. ABSTRACT
A
s providers of health care, jails face many of the same challenges that community health care providers face: how to provide better care, including better continuity of care, at lower cost. Yet jails face unique challenges as well. They provide health care to a highly mobile, largely uninsured population with higher-thanaverage rates of mental illness, substance abuse, and chronic diseases such as diabetes and HIV/ AIDS. And they often do so without benefit of linkages to local health providers. Without accurate medical information about inmates upon admission, jails sometimes struggle to provide adequate, timely care. And without continuing care in the community, former inmates’ health suffers, and they add to the community health burden, ultimately increasing health spending. Health information technology (IT) promises solutions. The movement to implement new in-
Judy Murphy is deputy national coordinator for programs and policy at the Office of the National Coordinator for Health Information Technology, Department of Health and Human Services, in Washington, D.C.
formation technologies, including electronic health record (EHR) systems and health information exchange, has accelerated across the mainstream health care delivery system, largely in response to a range of federal policy initiatives, technological developments, and market forces. Adoption of health IT by jails has in many ways mirrored adoption efforts by providers outside the jail walls. Some jails continue to use paper records, but others are migrating to EHR technology. A few have relatively sophisticated information systems that interface with jail management systems, EHRs, pharmaceutical systems, and electronic medication administration records. Some pioneering jurisdictions, such as Hampden County in Massachusetts, have developed their own EHR systems. Others have purchased and implemented systems developed for non–correctional settings, such as products used in hospitals or clinics. EHR systems developed March 2014
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Health specifically for correctional settings are also available. In addition, several proprietary companies that contract to provide health care in correctional facilities have developed their own EHR systems for implementation among their prison and jail clients. Fortunately for the nation’s jails, the policy environment is favorable for the adoption and expansion of EHRs and other health IT in the correctional setting. In this article we examine how decisions external to jails—coming from the Supreme Court, Congress, and local policy makers—have contributed to the growth of health IT in jails, leading to an opportune moment for many jurisdictions to intensify their efforts to adopt health IT, implement it more effectively, and use it to create connectivity between their jail and the surrounding community. We begin with the 1976 US Supreme Court decision in Estelle v. Gamble and continue through the 2009 passage of the Health Information Technology for Economic and Clinical Health (HITECH) component of the American Recovery and Reinvestment Act (ARRA) and 2010’s Affordable Care Act (ACA). Although many of the forces we identify are national in scope, local communities will play a major role in implementing health IT in jails. By way of example, we look at four jurisdictions where local forces furthered health IT in jails. The range in sophistication these systems represent provide a snapshot of where our nation’s jails are now with regard to health IT. In this article we also consider challenges that the Health Insurance Portability and Accountability Act (HIPAA) presents with regard to health IT in jails and how some jurisdictions have overcome them.
Background On The Jail Population Every year about ten million people are incarcerated in the nation’s 3,300 local and county jails. As a population, they have significantly higherthan-average rates of mental illness; substance addiction; and chronic and infectious diseases, including hypertension, diabetes, tuberculosis, HIV/AIDS, and hepatitis B and C.1 Unlike prison inmates, who are incarcerated for sentences of at least a year, jail detainees are generally released quite quickly back into their home communities, with 60 percent out within a week.2 After release, without insurance or a regular care provider, they generally go without continued treatment for whatever health problems they may have, which then worsen and become part of the community health burden. Thus, the investment made in inmates’ health while they are in jail is lost almost as soon as they return to the community. Untreated health 488
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problems, particularly mental illness and substance abuse disorders, often contribute to repeat offenses and recidivism, which, of course, incur additional costs to society. Meanwhile, as in the mainstream health care delivery system, health care costs present a serious challenge to many correctional institutions, which typically spend 9–30 percent of their budgets on inmate health care services. In Washington, D.C., for example, inmate medical services at the jail cost about $33 million in 2012, a quarter of the city’s annual corrections budget.3 Camden County, New Jersey, spent $11 million for inmate health care—22.25 percent of its health care budget and approximately 3.2 percent of the county’s entire $343 million budget for 2013 (Holly Cass, County Operations at County of Camden, New Jersey, personal communication, September 2013). The Multnomah County (Oregon) Health Department spent $2.8 million on health care in Portland’s jails— approximately 9 percent of the department’s budget (Nancy Griffith, Multnomah County Health Department, personal communication, September 2013).
Estelle V. Gamble The US Supreme Court decision in Estelle v. Gamble (1976) established that jails must meet the medical needs of the people in their custody. Failure to do so violates the Eighth Amendment, prohibiting cruel and unusual punishment. The Court also established a “constantly changing standard of required care because the right [of inmates to care] is based on evolving standards of health care in the general community.”4 As the expected standard of care in the community rises to meet new demands, so does the required standard of care in the local correctional setting. For example, forty years ago HIV/AIDS had not yet been diagnosed; today 13–19 percent of people with AIDS have had involvement with the correctional justice systems.5 Likewise, forty years ago most people with serious mental illnesses were in mental hospitals; today, many local and county jails are de facto providers of mental health care in their communities. Not only did Estelle place a broad mandate on correctional facilities to meet inmates’ health care needs, but it also said that cost concerns cannot outweigh that obligation. Facilities that practice “deliberate indifference” and ignore an inmate’s serious medical need can be sued. Since the Estelle decision, correctional officials’ failure to meet the health care obligations it established has resulted in numerous costly lawsuits and injunction decrees. Estelle does not dictate to jails how they must provide inmate care. They
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may employ their own medical staff, use public health departments, or contract with individuals or companies. Today a large city jail may serve as many people as a medium-size hospital, with its own on-site clinics, laboratories, and pharmacies. For example, the New York City jail system, the second-largest in the country after Los Angeles County, conducts nearly 750,000 medical and mental health visits a year, resulting in more than 600,000 prescriptions.6 Proprietary providers such as Corizon Health and Correctional Healthcare Companies contract with hundreds of prisons, jails, and other correctional facilities across the country to provide inmate care.
Four Jurisdictions, Four Health IT Implementations The examples of four disparate jurisdictions— Orange County (Orlando), Florida); Multnomah County (Portland), Oregon; New York City; and Hampden County (Springfield), Massachusetts)—provide a snapshot of the range of health IT options jails across the country have chosen and the forces driving those choices. Florida In Orange County an oversight commission active during the 1990s issued a set of 260 recommendations for improving health care and security at the county jail in Orlando, including updating the jail’s health IT infrastructure. In response, the jail purchased a new offender management system (OMS)7 and integrated it with a new EHR. This system went live in 2005. The integration has helped the jail manage inmates’ medical risk in several ways. Demographic data entered at booking automatically populate the EHR. If the inmate is a repeat admission, his or her medical record from previous incarcerations appears. The integration also supports automatic transfer of medication order records from the pharmacy system to the OMS, providing a record of distribution. Another interface between the OMS-based inmate sick-call system and the jail’s EHR system has significantly improved triage, tracking, and documentation. Under the former paper-based system, sick-call requests could be misplaced or lost. Under the new system, requests submitted by inmates are electronically transferred to the EHR, and a nurse can then triage the requests. Oregon The Health Department in Multnomah County oversees health care at the jail. In 2006 the county auditor recommended an EHR at the jail. The Health Department had implemented an EHR in its nonjail clinics and wanted to bring it to the jails as well. This was problematic because it was a difficult EHR to implement in the jail environment: It did not integrate with the jail management system (JMS); it did not
track inmate location (location tracking is especially important in a jail setting); and its computerized physician order entry system was not compatible with the jail’s correctional pharmacy system. Despite these drawbacks, the Health Department’s overriding concern for the health care of the entire county population prompted it to adopt (after an attempt to implement a different EHR) a unified EHR system across community clinics and in the jail. The EHR in the jail went live in 2012. Fourfifths of health care providers in the Portland area now use the same EHR that is used in the jail (Jennifer McClure, Multnomah County Health Department, personal communication, May 9, 2013). This specific EHR allows for the sharing of data between different installations at hospitals, clinics, and the county’s jails, in effect allowing health information exchange. New York In New York City the Department of Health and Mental Hygiene, which oversees correctional health in the city’s eight jails, also administers the Primary Care Information Project, which supports EHR adoption among primary care providers that work with underserved populations. Because the department recognized that the jail health care system is a critical part of the community safety net system, it has been working to bring the jails into the PCIP as well. Within the jail setting, the new EHR has been integrated with the inmate information system (IIS), in much the same way that Orange County integrated its information systems, including a pharmaceutical interface. In addition, the New York City department has built interfaces between jail system’s EHR and the Brooklyn Health Information Exchange (recently merged into the Healthix, a regional health information organization, which in turn connects with the Statewide Health Information Exchange of New York). This is the first step in achieving health information exchange between the jail system and community providers. Massachusetts In Hampden County, the Sheriff’s Department, under the leadership of Sheriff Michael Ashe, developed its own EHR, which it calls HealthTRAX; it went live in September 2003. The system allows providers to enter information about inmates’ medical history, problems, diagnoses, medications, counseling, dental care, and vision care. Medication orders entered into HealthTRAX are sent electronically to the pharmacy system, which verifies orders and relays warnings back to HealthTRAX in the event of duplicate orders or potential drug interactions. Having an internally developed system means that when problems arise, they usually can be resolved in-house, without the necessity of an outside vendor or consultant. March 2014
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Health Laws Accelerate Correctional Health IT Adoption Meaningful Use The HITECH Act authorized the spending of up to $44 billion to promote the adoption of health IT. Under HITECH, the State Health Information Exchange Cooperative Agreement Program was created to fund states’ efforts to build capacity for health information exchange across the health care system both within and across states. The HITECH Act also created an EHR incentive program, in which eligible Medicare and Medicaid providers that adopt certified EHRs can attest that they are “meaningful users” in order to receive incentive payments. One of the major goals of meaningful use is to establish health information exchange—hence the emphasis in HITECH on funding the development of health information exchanges. At first, providers in correctional institutions were not considered eligible for the meaningfuluse program because they were not Medicaid providers. The criterion for being eligible as a Medicaid provider was that 30 percent of a provider’s patient volume be for paid Medicaid encounters. However, states either terminate or suspend Medicaid upon incarceration; as a result, correctional providers are not able to bill Medicaid. Even though the ACA’s expansion of Medicaid to low-income people meant that many of those cycling through jails would have a higher likelihood of being enrolled in Medicaid, this still did not allow providers in corrections to participate in meaningful use, because the billing requirement was still in effect. Correctional Providers As Medicaid Providers The ability for correctional providers to become Medicaid providers and thus participate in the meaningful-use program came about in 2012, when the Centers for Medicare and Medicaid Services (CMS) expanded criteria for certifying a Medicaid provider. This expansion allowed for Medicaid enrollment (along with paid encounters) to be counted toward the 30 percent patient volume needed for a provider to qualify as a Medicaid provider. So for correctional providers in states that have expanded Medicaid, meaningful-use incentives suddenly became an option.8 The incentive program is financially appealing to jails. Each Medicaid provider can receive up to $63,750 for completing all three stages of attestation for meaningful use (Medicaid providers who can attest for meaningful use include all physicians at the jail plus nurse practitioners and midwives). The Medicaid meaningful-use program is aimed at individual providers, but providers are permitted to assign the payment to their employer—in this instance, a correction-
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al institution. For adopting, implementing, and updating to a certified EHR, in the first year of Stage 1 of meaningful use, a Medicaid provider can receive $21,250. Challenges Attesting for all of the stages of meaningful use and thereby receiving the total incentive payment is challenging for many providers in a jail environment. For example, allowing patients access to their medical records via the Internet is a requirement for Stage 2. Meeting this requirement is potentially difficult for providers in jails, as safety and security considerations—always primary within corrections—often argue against allowing detainees such access.9 Also, the time frames are tight, since 2016 is the last year a provider can begin participating in the Medicaid meaningful-use program. Nevertheless, these developments have opened up the possibility that correctional health care providers, like their non–correctional health care provider counterparts, could be exchanging health data in order to improve care and lower costs. Among the four jails discussed in this article, only the Department of Health and Mental Hygiene in New York City has begun the attestation process. This has meant that the department has had to verify that 30 percent of its patient volume is with Medicaid-enrolled individuals, the providers are certified Medicaid providers, and the providers are assigning payment to the department. The various requirements of Medicaid meaningful use may at first glance seem trivial; however, they are nevertheless prohibitive if not met. Orange County cannot participate in the meaningful-use program because Florida has not yet expanded Medicaid, and so it is highly unlikely that the threshold of 30 percent patient volume enrolled in Medicaid can be met. Although Massachusetts has expanded Medicaid, HealthTRAX, which was developed in house, is not yet a certified EHR. The Health Department of Multnomah County has a certified EHR and is in a state that has expanded Medicaid, but it is not currently collecting enrollment status because at this time the department is not prepared to make a new business case to justify the additional investment of staff resources (McClure, personal communication, December 2013).
Privacy Laws, Health Information Exchange, And Corrections The HIPAA Privacy Carve-Out One of the main goals of the HITECH Act was to promote health information exchange, and meaningful use is one of the means to achieving that goal. Thus, it is natural to inquire how HIPAA applies to
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The environment for health IT has never been more promising than it is now, and this is encouraging news for jails.
health data exchange when correctional institutions are involved. HIPAA explicitly allows these institutions to access inmates’ health information for the purpose of maintaining safety and security.10 However, community providers do not always understand or recognize this carveout for correctional institutions, which makes it difficult for jails to retrieve such information from the community providers. In New York State the HIPAA carve-out is recognized by the Statewide Health Information Network of New York (SHIN-NY). EHR data from health care providers that participate in health information exchange organizations are loaded without requiring patient consent. However, for a provider to access data from another provider, consent must be given, except in emergencies, at the time the data are being accessed. The New York City Department of Health and Mental Hygiene considers arrest an emergency situation, so the jails’ EHR is being modified to implement this policy. In the nonjail environment, the default is to obtain consent to access data, but in the jail system’s EHR, the default will be set to emergency access. Once a person is no longer incarcerated, the jail cannot view that person’s data without obtaining consent. Becoming A Covered Entity Organizations that establish health information exchanges often require participating providers to be covered entities under HIPAA (a covered entity is a health care provider transmitting health information electronically, a health care clearinghouse, or a health plan). This is a step that some jails do not want to take because they view the consent and privacy requirements for covered entities to be burdensome. Yet the benefits for the jail to participate in health information exchange— quickly identifying known health conditions, lowering costs, and perhaps reducing recidivism by providing continuous treatment—may outweigh the burden. There are examples of jails designated as cov-
ered entities and participating in health information exchange. New York City’s correctional system, whose health care provider is a covered entity, interfaces with health information exchange (as discussed above). Kentucky’s health information exchange, known as the KHIE, requires all providers who join it to be covered entities. The director of the Lexington jail, who is in the process of joining the state’s health information exchange, was willing to designate the jail as a covered entity in order to participate. He views the exchange of health data as means to enhance the care provided at his institution (Rodney Ballard, director, Fayette County Jail, personal communication, May 17, 2013). Substance Abuse Disorders There is no carve-out for correctional institutions to access data on inmates’ substance abuse disorders.11 A federal confidentiality regulation known as 42 CFR Part 2 stipulates the privacy of information concerning substance abuse disorder treatment for organizations receiving federal funds. Because this regulation was designed to encourage people to seek treatment, it is much stricter than HIPAA with regard to privacy. In addition, the conditions of consent—to whom, for how long, and for what purpose—are very specific. As a result, many community providers involved in health information exchange avoid exchange of data related to substance abuse treatment. In response, the Office of the National Coordinator for Health Information Technology has launched an initiative to explore the sharing of sensitive data using a data segmentation approach that allows individuals to specify which data a provider may access. The outcome of this initiative could be very valuable in a post-ACA world in which mental health and substance abuse disorder treatments are covered at parity with medical benefits. As a result of parity, there is a greater opportunity for jail-involved individuals to seek help for their substance abuse disorders. It may seem counterintuitive to remove data in order to promote better health care, but data segmentation initiatives that maintain restrictions on substance abuse treatment might be beneficial for health outcomes and reducing recidivism, if fear of disclosure is preventing someone from seeking treatment. When Washington State provided substance abuse treatment to addicted, very low-income childless adults, rates of re-arrest were 17–33 percent lower, compared with those among other addicted adults who did not receive treatment.12
Conclusion Increasingly, both the health care and the criminal justice sectors are recognizing the benefits of March 2014
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Health connecting correctional health care and community health care. The justice-involved population is not a population separate from the general community. It is a subpopulation of a highly vulnerable, high-cost, and underserved population whose health problems contribute substantially to the overall community health burden. As policy makers have struggled to find ways to control soaring health care costs, it has become clear that those efforts cannot succeed without taking into account the substantial health care costs incurred by the jail population. By extending Medicaid eligibility to very lowincome childless adults, the ACA creates an opportunity to manage some of those costs, especially with regard to treatment for mental illness and substance abuse. For states that have chosen to expand Medicaid, the people cycling through jails will have better opportunities to seek treatment for their underlying health conditions in the community because they now are eligible for insurance. For states expanding Medicaid that suspend it instead of terminating it when a Med-
icaid enrollee is incarcerated, jails and their health care providers can take advantage of HITECH meaningful-use incentives to adopt EHRs and participate in health information exchanges. The environment for health IT has never been more promising than it is now, and this is encouraging news for jails. As health care providers to some ten million people a year, jails—like other health care providers—are challenged to find ways to improve care while maintaining or lowering costs. By enabling the flow of information essential for delivering more coordinated, efficient, and sustained health care to the vulnerable and costly justice-involved population, health IT can serve as a bridge connecting jails and their communities. Jails can look to HITECH and the ACA not only as a way to better fulfill their obligations to provide health care to detainees but also as a rare confluence of events that can permit them to integrate within the greater health care community. ▪
NOTES 1 Conklin TJ, Lincoln T, Wilson R. A public health manual for correctional health care. Ludlow (MA): Hampden County Sheriff’s Department; 2002 Oct. 2 Minton TD. Jail inmates at midyear 2012—statistical tables. Washington (DC): Department of Justice, Bureau of Justice Statistics; 2013 May. 3 Schaenman P, Davies E, Jordan R, Chakraborty R. Opportunities for cost savings in corrections without sacrificing service quality: inmate health care. Washington (DC): Urban Institute; 2013 Feb 26. 4 Wright LN. Health care in prison thirty years after Estelle v. Gamble. J Correct Health Care. 2008;14(1): 31–5. 5 Veysey B (Rutgers—The State University of New Jersey, Newark, NJ). The intersection of public health and public safety in U.S. jails: implications and opportunities of federal
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health care reform [Internet]. Oakland (CA): Community Oriented Correctional Health Services; 2011 Jan [cited 2013 Oct 1]. Available from: http://www.cochs.org/files/ Rutgers%20Final.pdf 6 Stazesky R, Hughes J, Venters H (Department of Health and Mental Hygiene, New York, NY). Implementation of an electronic health record in the New York City jail system [Internet]. Oakland (CA): Community Oriented Correctional Health Services; 2013 Apr [cited 2013 Oct 1]. Available from: http:// www.cochs.org/files/hieconf/ implementation-ecw-new-york.pdf 7 The functions of an offender management system (OMS)—sometimes called an inmate information system (IIS) or a jail management system (JMS)—include tracking housing or location of inmates; inmate calendars, which can include court dates
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and medical appointments; dietary restrictions; bunking assignments due to physical disabilities; and other crucial information necessary for the running of a correctional institution. 45 CFR parts 412, 413, and 495. Access to computers, especially access to the Internet, is perceived as a threat because it presents the possibility of permitting communication that can be related to gang issues, contraband, and other criminal activity. 45 CFR sec. 164.512. 42 CFR part 2 sec. 2.1. Mancuso D, Felver BEM. Providing chemical dependency treatment to low-income adults results in significant public safety benefits. Olympia (WA): Washington State Department of Social and Health Services, Research and Data Analysis Division; 2009 Feb. (Report No. 11.140).
